Texas Patients Hit With Surprise Bills By Out-Of- Network Doctors By: Carrie Feibel, October 02nd, :30 AMCarrie Feibel

MC and in-Network Care Most insurance plans these days use a network system, whether that’s through a health maintenance organization (HMO) or a preferred provider organization (PPO). In these plans, doctors and hospitals in the network have agreed to a fixed payment rate, but doctors and hospitals outside the network can charge whatever they want. These systems have helped to control costs. But consumer advocates are learning more about problems with this model. For example, many patients assume that if they go to a hospital that is “in network,” the doctors who work there will also be “in network.” But that’s not necessarily true: emergency room doctors, radiologists, and anesthesiologists are often not part of insurance networks. Later, back at home, patients often receive a separate bill from those “out of network” doctors. It’s called a balance bill.

Separate Billing Patients can get balance bills even when they have no time to decide where to seek care, like during an emergency. Jeffrey Hopper of Austin had an emergency in June, after he was struck in the eye while coaching Little League. “His eye was swollen shut enough that we weren’t sure if he could see,” recalled his wife, Jennifer Hopper. She made sure to drive him to an in-network hospital. But even after co-pays, the emergency room doctor billed them separately for more than $700. “It felt kind of random,” she said. “How do I know who’s going to charge me and who’s not going to? So that was the first question.”

Wow! The Center for Public Policy Priorities, a think tank in Austin, recently analyzed the problem. It looked at the state’s three biggest insurers – Humana, Blue Cross and United.Center for Public Policy Priorities The report found that at 56% of Humana’s network hospitals in Texas, none of the ER doctors were actually in Humana’s network. Humana patients who went to emergency rooms at those hospitals would almost certainly receive a balance bill from an out-of-network physician.report For United, this occurred at 45% of its network hospitals and for Blue Cross, at 21%. At other hospitals, some of the doctors are in network, and some aren’t.

ER Doctors have different perspective The Texas insurance industry says it would like ER doctors to join their networks, but they can’t force them to. Emergency room doctors have a different perspective, saying insurance companies have been underfunding emergency care for years. Insurance companies often don’t pay ER doctors enough, even if they do join the network, said Dr. Bruce Moskow, president of the Texas College of Emergency Physicians.sayingTexas College of Emergency Physicians He added that the economics of ERs are complex. Unlike primary care doctors, ER doctors can’t screen potential patients to find out which insurance they have, if any. “In an emergency department, we see everyone and we’re not even legally allowed to ask if they’re going to pay their bill and large numbers of people pay nothing,” Moskow said.

Epilogue After his accident, Jeffrey Hopper’s vision was not damaged. But he did sustain a fracture to an orbital bone. Jennifer Hopper spent weeks appealing the ER bill and finally filed a complaint with state regulators. After that, she said, that balance bill simply disappeared. But she says nothing has really changed. She tried to get ready for the next ER visit, by searching her plan to find ER doctors who are in-network. But she found less than five in all of Austin. She realized that she probably won’t get those doctors the next time she or a family member rushes to the ER.

Some States Some states have tried to tackle the problem. In California, ER doctors can’t send a separate bill to HMO patients. In New York, a new law requires out-of-network doctors and insurers to hash out disputed payments on their own, and leave patients out of it. Texas insurers have indicated they’d be receptive to more reforms, such as expanding the mediation process. It’s currently restricted to balance bills over $1,000 and certain types of PPOs.

Is this a Market Failure? What does this say about the payments to the ER doctors? –Shouldn’t wages be increasing? What does this say about the MCO marketplace. –Shouldn’t there be entry?